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expert reaction to media reports suggesting that the pandemic response work of PHE may be merged with NHS Test and Trace into a new body called the National Institute for Health Protection

There have been media reports, notably in The Sunday Telegraph*, that Public Health England (PHE) may be dissolved and its work merged with NHS Test and Trace to form a new body called the National Institute for Health Protection.

 

Prof Richard Tedder, Visiting Professor in Medical Virology, Imperial College London, said:

“The apparent vilification of Public Health England by Mr Hancock is regrettable and will do little to deflect criticism of the government for its handling of SARS CoV 2. The government were in authority at the beginning and, as now, remain in authority and that is where inevitably the buck stops.

“It is even now not the time for recrimination. Public Health England and in its former existence as the Public Health laboratory Service remains an assembly of some of the wisest and most committed microbiologists and epidemiologists you could hope for anywhere. The persistent meddling from on-high has disenfranchised and fractured these staff to the great detriment of the UK as a whole and particularly for England. The recent Directors of the PHE National Infection Service and perhaps DoH should be held responsible for letting their teams down, not those in PHE who have remained so fully committed.

“For the Government to intend to force the existing laboratory staff into the NHS Trace and Treat is not only misplaced but will further dismantle the expertise that exists with PHE and which is irreplaceable.  By all means harness but do not destroy that which we already have.”

 

Dr Julian Tang, Honorary Associate Professor in Respiratory Sciences, University of Leicester, said: 

“There has been ongoing criticism1 of the overall UK approach – some of which could also apply to other European countries and North America.

“The truth is that there were plenty of lessons that UK, Europe and North America could have learnt from the Asian countries who experienced SARS 2003, if they were willing.2

“But there may have been additional cultural or historical barriers and a reluctance to learn from these Asian countries – together with the assumption that this SARS-CoV-2 (like SARS-CoV-1 in 2003) was just yet another ‘Asian problem’ – as many were former colonies of the UK and European countries.

“Enhanced, rapid public health interventions in these Asian countries, primed by experience of SARS (2003 – Hong Kong, Singapore, Taiwan, Thailand, Vietnam, Japan), MERS (South Korea), avian influenzas (Vietnam, Thailand, Hong Kong, China), Zika virus (Singapore) has created a very low threshold in these populations of recognising the potential for epidemic/pandemic spread of such emerging viruses. Having worked in Hong Kong and Singapore post-SARS 2003, and experiencing and working within these hypervigilant populations for 7-8 years, I can see that there is a substantial difference in their approach to such risks – compared to the UK.

“However, despite this lack of experience, the British public have learned very quickly to be more risk aware – and if consistent messaging was put in place earlier on (based on the Asian countries experience and advice), the number of cases and deaths could have been reduced substantially. This is illustrated by these US modelling studies on the potential number of lives that could have been saved if interventions like lockdown and masking were put in place much earlier.3

“Unfortunately, the confusion was on multiple fronts including ‘masks don’t work – but now they do’, ‘asymptomatic cases don’t transmit – but now they do’, ‘it’s not airborne – but now it is’, and ‘wearing masks make people take more risk – but actually they don’t’.

“Based on the lessons learned from COVID-19, In future, the UK and other public health teams should:

  1. Take emerging epidemic (with pandemic potential) threats seriously no matter where they are in the world, and prepare promptly and sufficiently for them. For this, they should include the input from multiple modelling teams – not just one – validated as far as possible with data from populations already affected
  2. Follow closely and take advice from the teams dealing with the emerging threat on the ground – what works, what doesn’t and prepare/resource/stockpile as needed. Yes, this may be difficult in the early stages, but equipment like PPE and ventilators are clearly of use, generically, for any respiratory pathogen
  3. Deliver clear messaging – and avoid a definitive statement when the answer is unclear. Black and white declarations like ‘masks don’t work’, ‘it’s not airborne’, and ‘asymptomatics don’t transmit’ have clearly backfired. Precautionary statements will now be more understandable and tolerated because (thanks to COVID-19) the public now understand better that evidence is not always black and white – and experts do not always agree. So the guidance needs to be precautionary and explanatory, e.g. ‘Although we don’t know for sure how much transmission is due to large droplets or fine aerosols, wearing masks will help for both scenarios, so wear masks in all indoor public areas, where ventilation is often insufficient to reduce such droplet/aerosol transmission.’
  4. Keep the public informed about the changing science underlying the changing guidance and explain the rationale. Otherwise, they will just ask anyway, e.g. ‘Why can hairdressers open but not nail bars?’, ‘Why can pubs open but not schools?’. The rationale behind this guidance also needs to be explained clearly – otherwise, if people don’t understand it, they won’t do it. Many of the Asian countries controlled COVID-19 well because they had clear messaging and the public compliance was high. There was less arguing over the evidence and therefore less delay in implementing useful interventions.”

1 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30727-3/fulltext

2 Vietnam: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7182304/

Taiwan: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7270822/

Japan: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7207161/

Hong Kong: https://www.cmaj.ca/content/192/19/E511; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7177146/

South Korea: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7194524/

Singapore: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7107552/

3 https://covid19.healthdata.org/united-states-of-america

https://www.sciencedirect.com/science/article/pii/S2468042720300117

https://www.medrxiv.org/content/10.1101/2020.05.27.20115139v5

 

Prof Sir Simon Wessely, Regius Professor of Psychiatry, Institute of Psychiatry Psychology & Neuroscience, King’s College London, said:

“PHE employs some of the best, brightest and most hardworking clinicians and experts we have.  There are simply not enough of them, which can partly be explained by the steady reduction in funding over the last seven years. Perhaps we do need a more joined up structure, but we should not scapegoat PHE for the failures in the system in which they are but one cog.”

 

Prof Paul Hunter, Professor in Medicine, UEA, said:

“The reports in the media that the UK government is likely to announce the reorganisation of Public Health England is perhaps no great surprise.  What is a surprise is that this is happening in the middle of the greatest public health challenge to the UK since the second world war.

“For a government keen to follow the science, then the theory and evidence on the impacts of major organizational change is clear.  Andrews & Boyne (2012)1 point out that ‘structural change has disruptive effects on managerial behaviour and organizational outcomes, and that these effects are likely to emerge in the period between the announcement and the commencement of the new structure’.  So we can certainly expect that an organisation and its doctors and scientists already struggling with the impact of a huge workload on top of chronic under-funding from austerity will struggle even more to cope with the likelihood of an imminent resurgence of the pandemic in the UK.

“If Public Health England is to change then the example of the Robert Koch Institute (RKI) in Germany may well be an appropriate model.  The RKI has a strong reputation for the quality of its research on infectious diseases as, it must be said, did the predecessor organisations to Public Health England (the Health Protection Agency and the Public Health Laboratory Service).

“Perhaps more crucially than organisational structure in any new organization is that it is adequately funded, Professor Whitty was correct when he told MPs that a major problem in the UKs response was lack of capacity as a result of austerity.  This lack of capacity was not just down to national funding allocations but also down to devolvement of public health services to local authorities without adequate ring fencing at a time when local authorities were also under severe financial restrictions (see Kings fund report https://www.kingsfund.org.uk/sites/default/files/2020-01/The_English_local_government_public_health_reforms_assessment_January_2020.pdf).

“But another issue for any new organisation will be its organizational culture.  For any new UK institute to be really effective it has to have and retain the best scientists.  Arguably RKI has been as effective as it has been because of the quality of its scientists and an environment that empowers these scientists.  Much has been said over the past decade of the rise of bureaucracy in universities and research institutes and the negative impact this may be having on research output.  Any new UK institute must enable its scientists and medical staff to respond rapidly and effectively to new threats and not be hampered by the organisation within which they work.  The organisational culture for effective science is not the same as that needed for state bureaucracies nor that needed for commercial organisations.  In this regard it is notable that the president of the RKI is a highly rated scientist himself.

“So if we do have to have a new health protection organisation please can this be adequately funded, please can this be science focussed and please can this be science led.  It should also have sufficient freedom and independence to speak truth even if that truth is unpalatable.”

1 Andrews R, Boyne G. Structural change and public service performance: The impact of the reorganization process in English local government. Public Administration. 2012 Jun;90(2):297-312.

 

Dr Amitava Banerjee, Associate Professor in Clinical Data Science and Honorary Consultant Cardiologist, Institute of Health Informatics, UCL, said:

“The reports in the media of a proposed “axing” of Public Health England (PHE) is of huge concern for at least four separate reasons.

“First, a major restructuring of public health function, as the global COVID-19 emergency continues, will distract limited resources (both human and financial) away from the simple public health measures of testing and tracing recommended by the World Health Organization in January 2020, which are still not in place seven months later.

“Second, PHE was set up as an executive agency of the Department of Health and Social Care by a Conservative government and is politically controlled, reporting directly to the Secretary of State for Health and Social Care.  Therefore, if PHE has fallen short, responsibility lies firmly with the current government and health ministers.

“Third, it is totally unclear what the new “National Institute for Health Protection” would be doing with regard to the wide range of PHE programmes outside of pandemic preparedness from cardiovascular diseases to mental health.  We risk damaging public health not just in relation to COVID-19, but far beyond.

“Fourth, in healthcare and healthcare research, there are clear principles regarding conflicts of interest.  In public life, the Nolan principles, established in 1995, include integrity, objectivity, accountability and openness.  Awarding of service contracts and appointment of leadership roles throughout the pandemic, and if now also happen in senior public health roles in a proposed new national institute, simply have not met and do not meet these standards.  As citizens, we expect the best people and providers to be appointed for such important roles, based on track record, skills and experience in open processes.  It is clear that the UK’s toll of excess deaths and economic recession is severe among developed nations.  Lack of transparency and accountability, as illustrated by an announcement in a newspaper late on a Saturday night during the A-levels crisis, have already had an appalling effect and need to be addressed urgently, not reinforced.

“Rather than a rash restructuring, a sensible approach must involve a rapid enquiry to establish lessons learned for future waves and future pandemics.  Moreover, this must include proper consultation with public health experts, scientists, service providers, patients and the public, if we are to be truly prepared in the current and future pandemics.”

 

Prof Neena Modi, Professor of Neonatal Medicine, Imperial College London, said:

“Media reports suggesting that PHE is to be scrapped and merged with NHS Test & Trace, to establish a new independent organisation tasked with protecting the nation against infectious pandemics begs major questions.  Public health encompasses far more than managing responses to infectious diseases; it is the primary means of safeguarding population health and wellbeing, including for example protection against obesity, cancers and poor air and water quality, and safeguarding reproductive health.  Where will responsibility lie for these matters and how will they be delivered?  This is particularly important given that the UK has a shockingly high prevalence of obesity, a postcode lottery for reproductive health services and poor air quality in urban areas.”

 

Prof Dame Til Wykes, Vice Dean Psychology and Systems Sciences, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, said:

“We need to be alert to any potential pandemic, so an organisation that will provide this concentrated alert and response function is a step forward.  Although a merger with a failing (and expensive) track and trace service does not provide much confidence in the final organisation.

“But also it begs the question of why?  PHE is under political control, this will not change so why will moving bits of it make any difference.  PHE has had a 40% decrease in its budget so carving it up will just mean too little resource spread even further.  Or it might be worse, a large chunk of the budget will move leaving less resource for making the UK healthier.  PHE is responsible for helping to decrease obesity and promoting mental wellbeing.  Both are vital to reduce the burdens on the NHS in the future.  So this may be a short term, diversion. Producing this disruption in the middle of a pandemic is a complete diversion.”

 

Prof Ilan Kelman, Professor of Disasters and Health, UCL, said:

“If this report is correct, then it demonstrates that those at the top continue to be talented at trying to prevent the disaster which just happened.  Kudos for thinking of and acting for possible future increases in coronavirus infection rates and other pandemics.  It is unclear why such measures were not implemented before this year given how important pandemics were in the UK’s National Risk Register.

“For apportioning blame and seeking improvements, elected decision-makers are ultimately responsible.  If government agencies deserve criticism and changes based on independently verified major mistakes, then similar standards should be applied to those at the very top.  Otherwise, we risk losing the experienced and knowledgeable employees at the bottom of the political hierarchy who have brought exceptional expertise and dedication to the recommendations for keeping us safe and healthy.”

 

Steve Bates, CEO of the U.K. Bioindustry Association, said:

“If England, (or the UK) is considering a rapid reorganisation of its public sector institutions to be better prepared for pandemic in future it’s imperative to consider at the same time the incentives for, and desired capacity within, the UK life science industry for the long term which compliment and work alongside public health agencies and scientists.

“At the core of the UK’s innovative response to COVID are companies with specific capabilities like Oxford Biomedica on rapid vaccine manufacturing scale up, Oxford Nanopore on next generation diagnostics and IQVIA on population based testing.

“However the deep scientific capability within PHE, for instance at Porton Down, and within NIBSC (as part of the MHRA) have been key to an effective ecosystem response and have worked rapidly and effectively with private sector partners this year.

“Germany has the Robert Koch Institute but it also has a differently organised diagnostics industry built over decades.

“For the UK to be one of the best equipped nations to response for this and future pandemics the government needs to consider strategic industrial and investment questions alongside reorganisation within the public sector.”

 

Dr Michael Head, Senior Research Fellow in Global Health, University of Southampton, said:

“These media reports suggest the government appears to be suggesting that Public Health England will be replaced with a National Institute for Health Protection, which sounds suspiciously like a Health Protection Agency, a model that was scrapped by this current government a few years back.

“If Matt Hancock does indeed consider PHE to be failing in its duties, then it may be worth considering that public health was brought under the control of the Department of Health and Social Care when the HPA was scrapped, and thus arguably any blame should be placed at Ministerial level.

“There are reports suggesting former telecoms executive Dido Harding will be giving the role of overseeing the new institute, which makes about as much sense as Chris Whitty being appointed the Vodafone Head of Branding and Corporate Image.”

 

Prof Robert Dingwall, Professor of Sociology, Nottingham Trent University, said:

“Basically this does look like an attempt to go back to the sort of structure that we had before the Lansley reforms.  As Exercise Cygnus showed, these had broken up the infrastructure on which pandemic planning depended – and which was led by the health department on behalf of the Cabinet Office not by PHE or its predecessor.  The organisational memory of the 2009 influenza pandemic, and its successful management, had also dissipated.  Cygnus showed that agencies didn’t know what their roles were or even where the documents to guide them had been filed.  Some didn’t even know they had a role.  Cygnus was not adequately followed up because the whole government apparatus was focussed on Brexit and other functions were starved of people and resources.

“Francois Balloux is right that the 2009 plan, as revised after Dame Deirdre Hine’s review, was a reasonable starting point.  The two viruses have enough in common to justify this, subject to revision as knowledge accumulated.  The big difference is that the influenza plan only looked to hold the ring with social and behavioural interventions until a vaccine was produced.  We know how to make flu vaccines but we don’t know how to make coronavirus vaccines.  It was never a question of just burying the dead but of slowing the movement of the virus through the population so that there were as few deaths as possible in the six months or so before the vaccine would be available.  Population immunity really is the only game in town with infectious disease.  Either you get it from surviving an infection or you get it from a vaccine.  If you don’t have a vaccine, the only thing you can manage is the speed with which people get infected.”

 

 

* https://www.telegraph.co.uk/politics/2020/08/15/hancock-axes-failing-public-health-england/amp/

https://www.telegraph.co.uk/politics/2020/08/15/phes-systematic-failure-exposed-disaster-ten-years-making/

 

All our previous output on this subject can be seen at this weblink:

www.sciencemediacentre.org/tag/covid-19

 

Declared interests

None received.

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